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Medical Pre-Authorisation Consultant

3 months ago

Pretoria, Gauteng, South Africa Qetello Holdings Full time

Together with our client in Pretoria, we are recruiting for a Medical Pre-Authorisation Consultant. The ideal candidate must have a completed qualification as an Enrolled Nurse and must be registered with SANC, with at least 2 years experience in Managed Healthcare.

Duties and responsibilities:

  • Receive applications for all services, which require pre-authorisation and attend to the request.
  • Capture clinical information and verify the information, including the applicable ICD-10 and item codes.
  • Validate and evaluate special pre-authorisation requests.
  • Prepare a summary of the members' clinical history for the medical advisor.
  • Monitor the flow of documents between the pre-authorisation division and the medical advisor.
  • Approve benefits accurately according to the benefits per benefit options and strictly according to protocols.
  • Escalate identified risks about specific members or providers to seniors.

Skills and Qualifications:

  • Grade 12
  • Completed qualification as an Enrolled Nurse
  • Registered with SANC
  • 2+ years of experience in Managed Healthcare
  • Good verbal and written English communication skills as well as proficiency in understanding Afrikaans spoken and written communication.
  • Computer literate in Ms Office.
  • Customer focus.
  • Must be able to work in a team and handle conflict situations.
  • Knowledge of the following:
    • Comprehensive knowledge of the Medical Scheme Act;
    • Sound knowledge of CPT-4, ICD-10 and RPL codes;
    • Extensive clinical knowledge;
    • Able to function independently with good decision-making skills; and
    • Exceptional work ethic.

Only candidates who meet all the requirements outlined in this advertisement will be considered. If you do not receive feedback from us within 2 weeks of your application, please consider your application unsuccessful.

To apply, please submit your CV and supporting documents to with the subject line "REF: Pre-Auth."